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Silva JT, Fernández-Ruiz M, Grossi PA, Hernández-Jimenez P, López-Medrano F, Mularoni A, Prista-Leão B, Santos L, Aguado JM. Reactivation of latent infections in solid organ transplant recipients from sub-Saharan Africa: What should be remembered? Transplant Rev (Orlando) 2021; 35:100632. [PMID: 34130253 DOI: 10.1016/j.trre.2021.100632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/07/2021] [Accepted: 05/29/2021] [Indexed: 11/30/2022]
Abstract
International migration from Sub-Saharan African countries to the European Union and the United States has significantly increased over the past decades. Although the vast majority of these immigrants are young and healthy people, a minority can be affected by chronic conditions eventually leading to solid organ transplantation (SOT). Importantly, these candidates can bear geographically restricted fungal and parasitic latent infections that can reactivate after the procedure. An appropriate evaluation before transplantation followed by treatment, whenever necessary, is essential to minimize such risk, as covered in the present review. In short, infection due to helminths (Schistosoma spp. and Strongyloides stercoralis) and intestinal protozoa (Entamoeba histolytica, Giardia lamblia or Cyclospora cayetanensis) can be diagnosed by multiple direct stool examination, serological assays and stool antigen testing. Leishmaniasis can be assessed by means of serology, followed by nucleic acid amplification testing (NAAT) if the former test is positive. Submicroscopic malaria should be ruled out by NAAT. Screening for Histoplasma spp. or Cryptococcus spp. is not routinely indicated. Consultation with an Infectious Diseases specialist is recommended in order to adjust preemptive treatment among Sub-Saharan African SOT candidates and recipients.
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Affiliation(s)
- Jose Tiago Silva
- Unit of Infectious Diseases, University Hospital "12 de Octubre", Research Institute Hospital "12 de Octubre" (imas12), Madrid, Spain.
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, University Hospital "12 de Octubre", Research Institute Hospital "12 de Octubre" (imas12), Madrid, Spain; Department of Medicine, Universidad Complutense, Madrid, Spain
| | - Paolo Antonio Grossi
- Department of Medicine and Surgery, University of Insubria and ASST Sette Laghi, Ospedale di Circolo of Varese, Varese, Italy
| | - Pilar Hernández-Jimenez
- Unit of Infectious Diseases, University Hospital "12 de Octubre", Research Institute Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, University Hospital "12 de Octubre", Research Institute Hospital "12 de Octubre" (imas12), Madrid, Spain; Department of Medicine, Universidad Complutense, Madrid, Spain
| | - Alessandra Mularoni
- Department of Infectious Diseases, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Beatriz Prista-Leão
- Department of Infectious Diseases, University Hospital Center "São João", School of Medicine, University of Porto, Porto, Portugal
| | - Lurdes Santos
- Department of Infectious Diseases, University Hospital Center "São João", School of Medicine, University of Porto, Porto, Portugal
| | - José María Aguado
- Unit of Infectious Diseases, University Hospital "12 de Octubre", Research Institute Hospital "12 de Octubre" (imas12), Madrid, Spain; Department of Medicine, Universidad Complutense, Madrid, Spain
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2
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Rosso F, Agudelo Rojas OL, Suarez Gil CC, Lopez Vargas JA, Gómez-Mesa JE, Carrillo Gomez DC, Meza Ramirez L, Caicedo Rusca LA. Transmission of malaria from donors to solid organ transplant recipients: A case report and literature review. Transpl Infect Dis 2021; 23:e13660. [PMID: 34057797 DOI: 10.1111/tid.13660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/19/2021] [Accepted: 05/22/2021] [Indexed: 12/12/2022]
Abstract
Malaria is a febrile and potentially fatal infection. It is typically transmitted to humans through the bite of Anopheles mosquitoes and less frequently can be contracted through blood transfusions, sharing contaminated needles and syringes, mother-to-child transmission, or after solid organ transplantation. Posttransplant malaria has rarely been reported in the literature, even in endemic areas. We report the cases of three solid organ recipients in which Plasmodium vivax infection was documented during postsurgical evaluation 30 days after transplant surgery. The diagnosis of donor-derived malaria was confirmed in all patients by demonstrating Plasmodium in a peripheral blood smear and by polymerase chain reaction (PCR). All recipients had symptoms. The liver transplant recipient had myalgia, arthralgia, and thrombocytopenia; the kidney transplant recipient developed acute renal failure; and the heart transplant recipient had fever, cephalalgia, and tonic-clonic seizures. Pre-transplant screening of donors and recipients from endemic regions may not be sufficient to safely rule out persistent malaria. In Colombia, according to legislation, no mandatory testing is required for the diagnosis of malaria in organ donors in nonendemic areas. Therefore, donor screening by questionnaire is the only tool for preventing transplant-borne malaria. The migratory trend from Venezuela to Colombia has increased the number of imported cases of malaria, and the infection may be present in endemic and nonendemic regions. Although donor evaluation is not standardized in current guidelines, we suggest that donors be tested for malaria with a peripheral blood smear, detection of specific IgG antibodies against Plasmodium, and techniques such as PCR, if possible.
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Affiliation(s)
- Fernando Rosso
- Centro de Investigaciones Clinicas (CIC), Fundación Valle del Lili, Cali, Colombia.,Infectious Disease Service, Internal Medicine Department, Fundación Valle del Lili, Cali, Colombia
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3
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Fürnkranz U, Walochnik J. Nosocomial Infections: Do Not Forget the Parasites! Pathogens 2021; 10:pathogens10020238. [PMID: 33669761 PMCID: PMC7923136 DOI: 10.3390/pathogens10020238] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/08/2021] [Accepted: 02/17/2021] [Indexed: 01/03/2023] Open
Abstract
Nosocomial infections (NIs) pose an increasing threat to public health. The majority of NIs are bacterial, fungal, and viral infections; however, parasites also play a considerable role in NIs, particularly in our increasingly complex healthcare environment with a growing proportion of immunocompromised patients. Moreover, parasitic infections acquired via blood transfusion or organ transplantation are more likely to have severe or fatal disease outcomes compared with the normal route of infection. Many of these infections are preventable and most are treatable, but as the awareness for parasitic NIs is low, diagnosis and treatment are often delayed, resulting not only in higher health care costs but, importantly, also in prolonged courses of disease for the patients. For this article, we searched online databases and printed literature to give an overview of the causative agents of parasitic NIs, including the possible routes of infection and the diseases caused. Our review covers a broad spectrum of cases, ranging from widely known parasitic NIs, like blood transfusion malaria or water-borne cryptosporidiosis, to less well-known NIs, such as the transmission of Strongyloides stercoralis by solid organ transplantation or nosocomial myiasis. In addition, emerging NIs, such as babesiosis by blood transfusion or person-to-person transmitted scabies, are described.
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Vernaza A, Pinilla-Monsalve G, Cañas F, Carrillo D, David López J, Flórez N, Gomez-Mesa JE. Malaria and encephalopathy in a heart transplant recipient: A case report in the context of multiorgan donation. Transpl Infect Dis 2021; 23:e13565. [PMID: 33432737 DOI: 10.1111/tid.13565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 12/10/2020] [Accepted: 12/30/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Malaria is an endemic infection in tropical circles. It can be transmitted from mosquitoes bite, but exceptional cases have been attributed to multiorgan transplantation. CASE REPORT This is a 34-year-old woman who received a heart transplant for final-stage dilated cardiomyopathy. Over the hospitalization, she developed fever, cephalalgia, and tonic-clonic seizures with MRI findings compatible with posterior reversible encephalopathy. A thick blood smear revealed hemoparasitic forms of Plasmodium vivax. Afterward, malaria was also diagnosed in recipients of one kidney and liver of the same organ donor. First-line treatment with artesunate was prescribed for 3 days and chloroquine with primaquine thereafter for 14 days. The patient was discharged and returned to the emergency department 5 days later, complaining of gastrointestinal symptoms and developed multiorgan failure that led to death. CONCLUSION We report a case of malaria transmission through heart transplantation. Despite adequate and supervised treatment, it can be related to a fatal outcome. Malaria screening in organ donors should be considered in regions where endemicity can lead to rare cases of transmission by transplantation.
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Affiliation(s)
- Armando Vernaza
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Cardiology, Fundación Valle del Lili, Cali, Colombia
| | - Gabriel Pinilla-Monsalve
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Neurology, Fundación Valle del Lili, Cali, Colombia
| | - Felipe Cañas
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Cardiology, Fundación Valle del Lili, Cali, Colombia
| | - Diana Carrillo
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Cardiology, Fundación Valle del Lili, Cali, Colombia
| | - Juan David López
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Cardiology, Fundación Valle del Lili, Cali, Colombia
| | - Noel Flórez
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Cardiology, Fundación Valle del Lili, Cali, Colombia
| | - Juan Esteban Gomez-Mesa
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Cardiology, Fundación Valle del Lili, Cali, Colombia
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Molina-Ortiz K, Puerta-Laverde V, Gutiérrez-Ocampo E, Villamizar-Peña R, Rodríguez-Morales AJ. Should we talk more about imported malaria in Bogotá, Colombia? Infect Dis Health 2019; 25:130-131. [PMID: 31813790 DOI: 10.1016/j.idh.2019.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/20/2019] [Accepted: 11/10/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Kevin Molina-Ortiz
- Public Health and Infection Research Group and Incubator, Faculty of Health Sciences, Universidad Tecnológica de Pereira, Risaralda, Colombia
| | - Valentina Puerta-Laverde
- Public Health and Infection Research Group and Incubator, Faculty of Health Sciences, Universidad Tecnológica de Pereira, Risaralda, Colombia
| | - Estefanía Gutiérrez-Ocampo
- Public Health and Infection Research Group and Incubator, Faculty of Health Sciences, Universidad Tecnológica de Pereira, Risaralda, Colombia
| | - Rhuvi Villamizar-Peña
- Public Health and Infection Research Group and Incubator, Faculty of Health Sciences, Universidad Tecnológica de Pereira, Risaralda, Colombia
| | - Alfonso J Rodríguez-Morales
- Public Health and Infection Research Group and Incubator, Faculty of Health Sciences, Universidad Tecnológica de Pereira, Risaralda, Colombia; Grupo de Investigación Biomedicina, Faculty of Medicine, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia.
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6
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Thellier M, Simard F, Musset L, Cot M, Velut G, Kendjo E, Pradines B. Changes in malaria epidemiology in France and worldwide, 2000-2015. Med Mal Infect 2019; 50:99-112. [PMID: 31257063 DOI: 10.1016/j.medmal.2019.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/11/2019] [Indexed: 12/15/2022]
Abstract
In 2015, 212 million new cases of malaria were reported, causing 429,000 deaths. The World Health Organization (WHO) estimated a 41% decrease in the number of new cases worldwide between 2000 and 2015. The number of deaths from malaria fell by 62% worldwide and by 71% in Africa. In mainland France, malaria is mainly imported by travelers or migrants from endemic areas, in particular sub-Saharan Africa (95%). In France, the number of imported malaria cases, mainly due to Plasmodium falciparum (85%), was estimated at about 82,000 for the period 2000-2015. Over the same period, 6,468 cases of malaria were reported in the French armed forces, of which 2,430 cases (37.6%) were considered as imported because occurring outside of endemic areas. The number of malaria cases also fell between 2000 and 2015 in Mayotte and French Guiana, a malaria transmission zone. Mayotte has entered the elimination of malaria with less than 15 cases per year. In French Guiana, between 300 and 500 cases have been reported annually in recent years. The decline in morbidity and mortality is usually attributed to vector control measures and improved access to effective treatments. However, the Anopheles mosquitoes that transmit the disease have developed resistance against most insecticides. Similarly, malaria parasites have developed resistance against most of the antimalarial drugs used as prevention or treatment, even the latest marketed combinations such as artemisinin-based combination therapies.
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Affiliation(s)
- M Thellier
- Service de parasitologie-mycologie, Centre national de référence du paludisme, hôpital Pitié-Salpêtrière, Assistance publique Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013 Paris, France; UMRS 1136, iPLESP, institut Pierre-Louis d'épidémiologie et de santé publique, Sorbonne université, 27, rue Chaligny, 75571 Paris 12, France; UPMC, faculté de médecine, Sorbonne université, université Pierre-et-Marie-Curie, 91, boulevard de l'Hôpital, 75013 Paris, France
| | - F Simard
- MIVEGEC, IRD-CNRS-university Montpellier, 911, avenue Agropolis, BP 64501, 34394 Montpellier, France
| | - L Musset
- Laboratoire de parasitologie, Centre collaborateur OMS pour la surveillance des résistances aux antipaludiques, institut Pasteur de la Guyane, 23, avenue Louis Pasteur, 97300 Cayenne, France; Centre national de référence du paludisme, institut Pasteur de la Guyane, 23, avenue Louis Pasteur, 97300 Cayenne, France
| | - M Cot
- UMR2016, unité Mère et enfant face aux infections tropicales, institut de recherche pour le développement, 4, avenue de l'Observatoire, 75006 Paris, France
| | - G Velut
- Centre d'épidémiologie et de santé publique des armées, GSBdD Marseille Aubagne, BP 40026, 13568 Marseille cedex 02, France; Direction interarmées du service de santé des armées, Quartier La Madeleine, 97306 Cayenne, France
| | - E Kendjo
- Service de parasitologie-mycologie, Centre national de référence du paludisme, hôpital Pitié-Salpêtrière, Assistance publique Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013 Paris, France; UMRS 1136, iPLESP, institut Pierre-Louis d'épidémiologie et de santé publique, Sorbonne université, 27, rue Chaligny, 75571 Paris 12, France; UPMC, faculté de médecine, Sorbonne université, université Pierre-et-Marie-Curie, 91, boulevard de l'Hôpital, 75013 Paris, France
| | - B Pradines
- Unité parasitologie et entomologie, institut de recherche biomédicale des armées, institut hospitalo-universitaire Méditerranée Infection, 19-21, boulevard Jean-Moulin, 13005 Marseille, France; Aix Marseille université, IRD, AP-HM, SSA, VITROME, institut hospitalo-universitaire Méditerranée Infection, 19-21, boulevard Jean-Moulin, 13005 Marseille, France; Institut hospitalo-universitaire Méditerranée Infection, 19-21, boulevard Jean-Moulin, 13005 Marseille, France; Centre national de référence du paludisme, institut hospitalo-universitaire Méditerranée Infection, 19-21, boulevard Jean-Moulin, 13005 Marseille, France.
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7
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Malaria Disease Recommendations for Solid Organ Transplant Recipients and Donors. Transplantation 2018; 102:S16-S26. [DOI: 10.1097/tp.0000000000002017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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8
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Richter J, Franken G, Holtfreter MC, Walter S, Labisch A, Mehlhorn H. Clinical implications of a gradual dormancy concept in malaria. Parasitol Res 2016; 115:2139-48. [PMID: 27079460 DOI: 10.1007/s00436-016-5043-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 04/07/2016] [Indexed: 12/15/2022]
Abstract
Malaria recurrences after an initially successful therapy and malarial fever occurring a long time after infection are well-known problems in malariology. Currently, two distinct types of malaria recurrences are defined: recrudescence and relapse. A recrudescence is thought to originate from circulating Plasmodium blood stages which do not cause fever before a certain level of a microscopically detectable parasitemia is reached. Contrary, a relapse is thought to originate from quiescent intracellular hepatic parasite stages called hypnozoites. Recrudescences would typically occur in infections due to Plasmodium falciparum. Plasmodium knowlesi, and Plasmodium malariae, whereas relapses would be caused exclusively by Plasmodium vivax and Plasmodium ovale. This schematic view is, however, insufficiently supported by experimental evidence. For instance, hypnozoites of P. ovale have never been experimentally documented. On the other hand, the nonfinding of P. malariae hypnozoites turned into the proof for the nonexistence of P. malariae hypnozoites. Clinical relapse-type recurrences have been observed in both P. ovale and P. malariae infections, and decade-long incubation times have also been reported in P. falciparum infections. We propose a gradual hypothesis in accordance with the continuity concept of biological evolution: both, relapse and recrudescence may be potentially caused by all Plasmodium spp. We hypothesize that the difference between the various Plasmodium spp. is quantitative rather than qualitative: there are Plasmodium spp. which frequently cause relapses such as P. vivax, particularly the P.v. Chesson strain, species which cause relapses less frequently, such as P. ovale and sometimes P. malariae, and species which may exceptionally cause relapses such as P. falciparum. All species may cause recrudescences. As clinical consequences, we propose that 8-aminquinolines may be considered in a relapse-type recrudescence regardless of the causal Plasmodium sp., whereas primaquine relapse prevention might not be routinely indicated in malaria due to P. ovale.
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Affiliation(s)
- Joachim Richter
- Tropical Medicine Unit, Department for Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany.
| | - Gabriele Franken
- Institute for the History of Medicine, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Martha C Holtfreter
- Tropical Medicine Unit, Department for Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Susanne Walter
- Institute for Zoomorphology, Cell Biology and Parasitology, Faculty of Biology, Heinrich-Heine-University, Düsseldorf, Germany
| | - Alfons Labisch
- Institute for the History of Medicine, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Heinz Mehlhorn
- Institute for Zoomorphology, Cell Biology and Parasitology, Faculty of Biology, Heinrich-Heine-University, Düsseldorf, Germany
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9
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Affiliation(s)
- Ali Dana
- Johns Hopkins Department of Dermatology, Baltimore, MD, USA
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10
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Beating the odds: factors implicated in the speed and availability of unrelated haematopoietic cell donor provision. Bone Marrow Transplant 2012; 48:210-9. [DOI: 10.1038/bmt.2012.54] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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11
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Abstract
Parasitic infections are an uncommon but potentially severe complication in solid organ transplant (SOT) recipients. An increase in donors who have emigrated from tropical areas and more transplant recipients traveling to endemic areas have led to a rise in parasitic infections reported among SOT recipients. Clinicians should include these infections in their differential diagnosis and promote adherence to preventive measures in SOT recipients.
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12
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Transplantation and tropical infectious diseases. Int J Infect Dis 2009; 14:e189-96. [PMID: 19647464 DOI: 10.1016/j.ijid.2009.04.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Revised: 04/03/2009] [Accepted: 04/14/2009] [Indexed: 02/08/2023] Open
Abstract
The number of transplant recipients with tropical infectious diseases is growing due to increasing international travel and the rising number of transplants taking place in the tropics and subtropics. With increases in population migration, the prevalence of individuals infected with geographically restricted organisms also rises. There are three potential categories of tropical infections in transplant patients: (1) donor-related infections transmitted by the graft or through transfusion of blood products; (2) reactivation or recrudescence of latent infections in the donor recipient; and (3) de novo acquisition of infection in the post-transplant period through the traditional route of infection. We present an overall discussion of the association of parasitic (protozoa and helminths) and non-parasitic (viral, bacterial, and fungal) tropical infectious diseases and solid-organ and hematopoietic transplantation. We also suggest potential screening guidelines for some of these tropical infections.
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13
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Mixed Plasmodium falciparum and Plasmodium vivax Malaria in Orthotopic Liver Transplant Recipient. Transplantation 2009; 88:288. [DOI: 10.1097/tp.0b013e3181acc314] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Martín-Dávila P, Fortún J, López-Vélez R, Norman F, Montes de Oca M, Zamarrón P, González MI, Moreno A, Pumarola T, Garrido G, Candela A, Moreno S. Transmission of tropical and geographically restricted infections during solid-organ transplantation. Clin Microbiol Rev 2008; 21:60-96. [PMID: 18202437 PMCID: PMC2223841 DOI: 10.1128/cmr.00021-07] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
In recent years, the increasing number of donors from different regions of the world is providing a new challenge for the management and selection of suitable donors. This is a worldwide problem in most countries with transplantation programs, especially due to the increase in immigration and international travel. This paper elaborates recommendations regarding the selection criteria for donors from foreign countries who could potentially transmit tropical or geographically restricted infections to solid-organ transplant recipients. For this purpose, an extensive review of the medical literature focusing on viral, fungal, and parasitic infections that could be transmitted during transplantation from donors who have lived or traveled in countries where these infections are endemic has been performed, with special emphasis on tropical and imported infections. The review also includes cases described in the literature as well as risks of transmission during transplantation, microbiological tests available, and recommendations for each infection. A table listing different infectious agents with their geographic distributions and specific recommendations is included.
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Affiliation(s)
- P Martín-Dávila
- Servicio de Enfermedades Infecciosas, Hospital Ramón y Cajal, Ctra. Colmenar km. 9,100, 28034 Madrid, Spain.
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